=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154831469
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILIA CORTES-LEBRON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2017
-----------------------------------------------------
Last Update Date | 05/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR 121 KM 13.3 SECTOR CUATRO CALLES, BO. SUSUA BAJA
-----------------------------------------------------
City | YAUCO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-987-8036
-----------------------------------------------------
Fax | 787-987-8234
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 CARR 116 STE 1
-----------------------------------------------------
City | YAUCO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00698-4693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-987-8036
-----------------------------------------------------
Fax | 787-987-8234
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE-PRESIDENT
-----------------------------------------------------
Name | MARISOL LEBRON
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 787-923-7178
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 19F3512
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------